GI Physical Exam CS 3 New

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Gastrointestinal system

Physical exam
Outlines
- General examination
General inspection
Hand examination
Face examination
Mouth, Throat & Tongue
Neck
 Chest
Lower limb

- Abdominal examination
- DRE
- Hernial orifice exam
General examination
The General inspection
Note the patient’s general appearance. Are they in pain, cachectic, thin,
well nourished or obese?
Orientation
 Record height, weight, waist circumference and body mass index .
Note whether obesity is truncal or generalised.
Loose skin folds signify recent weight loss.
Vital signs
Cachectic patient Truncal Obesity
Hands Examination
Inspect the patient’s hands for clubbing (IBD, Cirrhosis, Celiac),
koilonychia (spoon-shaped nails) and signs of chronic liver
disease, including leuconychia (white nails), Flapping Tremor
, Dupuytren’s Contracture and palmar erythema .
Eye Examination
Inspect Sclera for Jaundice.
Inspect conjunctiva for pallor.
Inspect the mouth, throat and tongue.
Mouth and throat aphthous ulcers are common in coeliac and
inflammatory bowel disease .
Stigmata of iron deficiency include angular cheilitis (painful cracks at the
corners of the mouth) and atrophic glossitis (pale, smooth tongue).

Aphthous ulcer
Angular cheilitis
Lymph node examination

Gastric and pancreatic cancer may spread to cause enlargement of


the left supraclavicular lymph nodes (Troisier’s sign).
CHEST

 Gynecomastia :
•Breast enlargement
in Males.
•Reduced breakdown
of Estrogens.

 Hair Distribution.
 Spider Nivea.
Lower Limbs

• Edema,
• Loss of hair
• Erythema nodosum .
Abdominal examination
Before Any
Examination
1- Introduce your self
2- Hand Hygiene
3- Explain and Take Permission
4- Privacy and ask if chaperone
5- Good light
6 Exposure : Expose the abdomen from the xiphisternum to the symphysis pubis, leaving
the chest and legs covered.

7 Ideal Position : comfortably supine with the head resting on only one or two pillows to
relax the abdominal wall muscles.
Inspection
From the Foot of the bed for :
1- Umbilicus
2- Abdominal respiration (absent in peritonitis)
3- Symmetry & Swelling
Inspect From the Right side of the bed for :
1- Skin note any scars, striae, bruising or scratch marks.
2- Visible dilated veins
Umbilicus
- is Normally located centrally and usually inverted .
- In obesity, the umbilicus is usually sunken; in ascites, it is
flat or, more commonly, everted.
Symmetry & Swelling :
-Look from the foot of the bed for any asymmetry suggesting
a localised mass.
- Abdominal swelling may be :
 Diffuse : Ascites or
Intestinal obstruction.
 Localized: urinary retention, mass or enlarged
organ such as liver.

Urine retention
Skin Bruising
 Bleeding into the falciform ligament; gives 2 Signs :
1 Cullen sign is a hemorrhagic discoloration of the umbilical area due to
intraperitoneal hemorrhage from any cause; one of the more frequent
causes is acute hemorrhagic pancreatitis.
2 Grey Turner sign is a discoloration of the left flank associated with
acute hemorrhagic pancreatitis.
Visible veins
Suggest Portal hypertension or Vena cava obstruction :
In portal hypertension, recanalisation of the umbilical vein along the
falciform ligament produces distended veins that drain away from the
umbilicus: the ‘caput medusae’.
 The umbilicus may appear bluish and distended due to an umbilical
varix.
In contrast, an umbilical hernia is a distended and everted umbilicus that
does not appear vascular and may have a palpable cough impulse.
Striae
•Asymmetric raised
linear streaks
(stretch marks).
 Rapid wt. gain.
 Pregnancy
 Cushing
Disease.
Palpation
 Any pain?
- If so; leave that area to the last.
 Kneel beside bed
 Warm hands
 Keep Eye-to-Eye contact
 Right hand
- keep it flat & in contact with abdominal wall.
Palpation
1- Light Superficial Palpation.
a.Gain patient’s confidence.
b.Superficial Masses.
c. Superficial Tenderness.
2- Deep Palpation.
a.Deep Masses.
b.Deep Tenderness.
c. Rebound
Tenderness? /
Murphy’s Sign?
3- Palpation For
Organomegaly:
- Liver, Spleen .
Tenderness

 Discomfort during palpation may vary and may be accompanied by resistance to


palpation, tenderness usefully indicates underlying pathology.

 Voluntary guarding : is the voluntary contraction of the abdominal muscles when


palpation provokes pain.
 Involuntary guarding: is the reflex contraction of the abdominal muscles when
there is inflammation of the parietal peritoneum.
 If the whole peritoneum is inflamed (generalised peritonitis) due to a perforated
viscus, the abdominal wall no longer moves with respiration; breathing becomes
increasingly thoracic and the anterior abdominal wall muscles are held rigid
(board-like rigidity).
 The site of tenderness is important. Tenderness in the epigastrium suggests
peptic ulcer; in the right hypochondrium, cholecystitis; in the left iliac fossa,
diverticulitis; and in the right iliac fossa, appendicitis or Crohn’s ileitis .
Palpable mass
 A pulsatile mass palpable in the upper abdomen may be normal aortic pulsation
in a thin person, a gastric or pancreatic tumour transmitting underlying aortic
pulsation, or an aortic aneurysm.
 A pathological mass can usually be distinguished from normal palpable
structures by site (Fig. 6.13), and from palpable faeces as these can be indented
and may disappear following defecation.
 A hard subcutaneous nodule at the umbilicus may indicate metastatic cancer
(‘Sister Mary Joseph’s nodule’).
Enlarged organs
-Examine the liver, gallbladder, spleen in turn during deep inspiration.
-Keep your examining hand still and wait for the organ to move with
breathing.
-Do not start palpation too close to the costal margin, missing the edge of
the liver or spleen.

1- Hepatomegaly :
 Place your hand flat on the skin of the right iliac fossa.
 Point your fingers upwards and your index and middle fingers lateral
to
the rectus muscle, so that your fingertips lie parallel to the rectus sheath
(Fig. 6.14).
 Keep your hand stationary.
 Ask the patient to breathe in deeply through the mouth.
 Feel for the liver edge as it descends on inspiration.
 Move your hand progressively up the abdomen, 1 cm at a time, between
each breath the patient takes, until you reach the costal margin or detect
the liver edge.
 If you feel a liver edge, describe:
• size • surface: smooth or irregular
• edge: smooth or irregular; define the medial border
• consistency: soft or hard • tenderness • pulsatility.

Liver Span : (by Percussion):

 Ask the patient to hold their breath in full expiration.


 Percuss downwards from the right fifth intercostal space in the
mid- clavicular line, listening for dullness indicating the upper border
of the liver.
 Measure the distance in centimetres below the costal margin in the
mid- clavicular line or from the upper border of dullness to the palpable
liver edge. [NL: 8-12cm].

 The normal liver is identified as an area of dullness to percussion over


the right anterior chest between the fifth rib and the costal margin.

 The liver may be enlarged or displaced downwards by hyperinflated


lungs.
The liver is enlarged in early cirrhosis but often shrunken in
advanced cirrhosis.
 Fatty liver (hepatic steatosis) can cause marked
hepatomegaly.
Hepatic enlargement due to metastatic tumour is hard and
irregular.
 An enlarged left lobe may be felt in the epigastrium or
even the left
hypochondrium.

In right heart failure the congested liver is usually soft and tender; a
pulsatile liver indicates tricuspid regurgitation.

A bruit over the liver may be heard in acute alcoholic hepatitis,


hepatocellular cancer and arteriovenous malformation , the most
common reason for an audible bruit over the liver, however, is a
transmitted heart murmur.
2- Gall
bladder
In a patient with right upper quadrant pain, test for
Murphy’s sign (see Box 6.9); a positive modestly
increases the probability of acute cholecystitis.

Murphy's sign is elicited in patients with acute


cholecystitis by asking the patient to take in and hold a
deep breath while palpating the right subcostal area. If
pain occurs when the inflamed gallbladder comes into
contact with the examiner's hand, Murphy's sign is
positive.
3- Splenomegaly
 The spleen has to enlarge threefold before it becomes palpable, so a
palpable spleen always indicates splenomegaly.
It enlarges from under the left costal margin down and medially
towards the umbilicus (Fig. 6.15B).
A characteristic notch may be palpable midway along its leading edge,
helping differentiate it from an enlarged left kidney .

Examination sequence:
 Place your hand over the patient’s umbilicus. With your hand
stationary, ask the patient to inhale deeply through the mouth.
 Feel for the splenic edge as it descends on inspiration.
 Move your hand diagonally upwards towards the left hypochondrium
(Fig. 6.16A), 1 cm at a time between each breath the patient takes.
 Feel the costal margin along its length, as the position of the spleen
tip is variable.
 If you cannot feel the splenic edge, palpate with your right hand,
placing your left hand behind the patient’s left lower ribs and pulling
the ribcage forward (Fig. 6.16B), or ask the patient to roll towards
you and on to their right side and repeat the above.
 Feel along the left costal margin and percuss over the lateral chest
wall.
 The normal spleen causes dullness to percussion posterior to the left
mid-axillary line beneath the 9th–11th ribs.
Percussion

 Normal note is Tympanic.


 Over mass or fluid gives DULL
 If obstruction, hyperresonance

 Percuss for Ascites


Ascites
Ascites is the accumulation of intraperitoneal fluid .
➢Shifting dullness:
mild-moderate
ascites.
➢Fluid transmitted
thrill: massive
ascites.
Examination sequence

Shifting dullness
•With the patient supine, percuss from the midline out to the flanks
(Fig. 6.17). Note any change from resonant to dull, along with areas of
dullness and resonance.
•Keep your finger on the site of dullness in the flank and ask the
patient to turn on to their opposite side.
•Pause for 10 seconds to allow any ascites to gravitate, then percuss
again. If the area of dullness is now resonant, shifting dullness is
present, indicating ascites.
Fluid thrill
 If the abdomen is tensely distended and you are uncertain whether ascites
is present, feel for a fluid thrill.
 Place the palm of your left hand flat against the left side of the patient’s
abdomen and flick a finger of your right hand against the right side of the
abdomen.
 If you feel a ripple against your left hand, ask an assistant or the patient to
place the edge of their hand on the midline of the abdomen (Fig. 6.18).
 This prevents transmission of the impulse via the skin rather than through
the ascites.
 If you still feel a ripple against your left hand,
a fluid thrill is present (detected
only in gross ascites).
Auscultation (Bowel sound & Bruit)
 With the patient supine, place your stethoscope diaphragm to the right
of the umbilicus and do not move it.
 Listen for up to 2 minutes before concluding that bowel sounds are
absent.
 Listen above the umbilicus over the aorta for arterial bruits.
 Now listen 2–3 cm above and lateral to the umbilicus for bruits from
renal artery stenosis.
 Listen over the liver for bruits.
Succussion splash test
- this sounds like a half-filled water bottle being shaken.
- Explain the procedure to the patient, then shake their

abdomen by rocking their pelvis using both hands.


 An audible splash more than 4 hours after the patient has eaten or
drunk anything indicates delayed gastric emptying, as in pyloric
stenosis.
Bowel sounds
Normal bowel sounds are gurgling noises from the normal
peristaltic activity of the gut.
 They normally occur every 5–10 seconds but the frequency
varies.
 Absence of bowel sounds implies paralytic ileus or peritonitis.
In intestinal obstruction, bowel sounds occur with increased
frequency and volume, and have a high-pitched, tinkling quality.
Bruits suggest an atheromatous or aneurysmal aorta or superior
mesenteric artery stenosis.
A friction rub, which sounds like rubbing your dry fingers together, may be
heard over the liver (perihepatitis) or spleen (perisplenitis).
Don’t forget to Mention that You Have to Examine ..

1. Hernial orifices.
2. DRE (PR).
Thank You

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